California Makes Waves With Pharma Benefits, Purchasing Plan

With Chart: California Medicaid Could Shift to Fee-for-Service Drug Benefit

January 24, 2019

Under the direction of its new governor, Democrat Gavin Newsom, California is planning to take control of the pharmacy benefit for all of the state’s Medi-Cal beneficiaries — the vast majority of which currently have that part of their care administered by private insurers and their PBMs. What’s more, the order directs state agencies to create bulk-purchasing arrangements for high-priority drugs, like those without generic alternatives, and establish a framework for letting private businesses and insurers join the state’s buying pool.

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Under the direction of its new governor, Democrat Gavin Newsom, California is planning to take control of the pharmacy benefit for all of the state’s Medi-Cal beneficiaries — the vast majority of which currently have that part of their care administered by private insurers and their PBMs. What’s more, the order directs state agencies to create bulk-purchasing arrangements for high-priority drugs, like those without generic alternatives, and establish a framework for letting private businesses and insurers join the state’s buying pool.

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New Model Prods Medicare Drug Plans to Take on More Risk

January 24, 2019

CMS’s Center for Medicare and Medicaid Innovation on Jan. 18 unveiled a new “Part D Payment Modernization model” to encourage plan sponsors to take on more risk in the catastrophic phase of coverage, where spending has ballooned in recent years.

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CMS’s Center for Medicare and Medicaid Innovation on Jan. 18 unveiled a new “Part D Payment Modernization model” to encourage plan sponsors to take on more risk in the catastrophic phase of coverage, where spending has ballooned in recent years.

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UnitedHealth Touts OptumRx’s Solid Earnings, Rising Script Volume

January 24, 2019

When UnitedHealth Group released its fourth-quarter and full-year 2018 financial results on Jan. 15, subsidiary OptumRx got its usual amount of attention with respect to earnings performance, script volume, client retention and sales. But this time around, UnitedHealth stressed its unit’s ability to compete in a new environment as combined companies from major industry mergers take shape. Management also downplayed the gradual loss of Cigna Corp.’s pharmacy business as a revenue hit but not a profit hit.

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When UnitedHealth Group released its fourth-quarter and full-year 2018 financial results on Jan. 15, subsidiary OptumRx got its usual amount of attention with respect to earnings performance, script volume, client retention and sales. But this time around, UnitedHealth stressed its unit’s ability to compete in a new environment as combined companies from major industry mergers take shape. Management also downplayed the gradual loss of Cigna Corp.’s pharmacy business as a revenue hit but not a profit hit.

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News Briefs

January 24, 2019

✦ CVS Health Corp. and Walmart Inc. said Jan. 18 they reached a multi-year agreement for Walmart to continue participating in the CVS Caremark PBM’s commercial and managed Medicaid retail pharmacy networks. The contract’s financial terms were not disclosed. With Walmart’s continuing participation, the CVS Caremark national pharmacy network will have nearly 68,000 participating pharmacies, including independently owned, community-based pharmacies, other local pharmacies in grocery stores and mass merchants, plus regional and national chains. The companies have an existing agreement for Walmart’s participation in the CVS Caremark Medicare Part D pharmacy network, and Walmart’s Sam’s Club division has an existing agreement to participate in the CVS Caremark pharmacy networks. See https://bit.ly/2U7OJy7.

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✦ CVS Health Corp. and Walmart Inc. said Jan. 18 they reached a multi-year agreement for Walmart to continue participating in the CVS Caremark PBM’s commercial and managed Medicaid retail pharmacy networks. The contract’s financial terms were not disclosed. With Walmart’s continuing participation, the CVS Caremark national pharmacy network will have nearly 68,000 participating pharmacies, including independently owned, community-based pharmacies, other local pharmacies in grocery stores and mass merchants, plus regional and national chains. The companies have an existing agreement for Walmart’s participation in the CVS Caremark Medicare Part D pharmacy network, and Walmart’s Sam’s Club division has an existing agreement to participate in the CVS Caremark pharmacy networks. See https://bit.ly/2U7OJy7.

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Opportunities for managed care plans abound in Medicare Advantage (MA), the popular, competitive program that seems to enjoy bipartisan support, experts tell AIS Health. Nationwide, the market has grown to approximately 3,700 MA plan choices in 2019, up from roughly 3,100 in 2018, and longtime industry consultant Stephen Wood predicts significant plan innovation from more flexibility within the program — along with generally strong plan enrollment despite challenges from heavy consolidation among large managed care companies and providers alike.

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Opportunities for managed care plans abound in Medicare Advantage (MA), the popular, competitive program that seems to enjoy bipartisan support, experts tell AIS Health. Nationwide, the market has grown to approximately 3,700 MA plan choices in 2019, up from roughly 3,100 in 2018, and longtime industry consultant Stephen Wood predicts significant plan innovation from more flexibility within the program — along with generally strong plan enrollment despite challenges from heavy consolidation among large managed care companies and providers alike.

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Prenatal Screens, Other DNA Tests Create Quandary for Payers

January 21, 2019

As genetic tests become increasingly accessible, they’re helping transform health care by connecting patients with more personalized diagnoses and treatments. But because of the way such tests are introduced and evaluated — as well as the breakneck pace of innovation — it’s often challenging for health plans to decide how to cover them, says Lon Castle, M.D., chief of molecular diagnostics and specialty drug management at eviCore healthcare.

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As genetic tests become increasingly accessible, they’re helping transform health care by connecting patients with more personalized diagnoses and treatments. But because of the way such tests are introduced and evaluated — as well as the breakneck pace of innovation — it’s often challenging for health plans to decide how to cover them, says Lon Castle, M.D., chief of molecular diagnostics and specialty drug management at eviCore healthcare.

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